Concussion suspected? You’rrrre outta the game, neurologists urge

Concussion research has yet to turn up therapies that can diminish the consequences of a mild traumatic brain injury or shorten the duration of its symptoms, the nation’s leading group of neurologists concluded on Monday. But in athletics, there is one step that can avert lengthening symptoms or exacerbating damage from a blow to the head, the American Academy of Neurology wrote: Take the athlete out of the game or off the practice field when a concussion is suspected, and delay his or her return to play until the all-clear has been issued by a trainer or physician skilled in diagnosing and treating brain injury.

In new guidelines issued Monday by the academy, coaches and sideline trainers are urged to be particularly conservative in applying those rules to younger athletes, those who’ve had past concussions, those who practice fewer than three hours a week and those who play in a game, such as hockey, in which body-checking is routine.

The new set of guidelines is the first update to the medical specialists’ recommendations since 1997. It underscores the value of putting athletes through a battery of cognitive tests before they begin participating in a sport. The neurologists concluded that those “baseline assessments,” which are increasingly required among high school and college-level athletic programs, give physicians, coaches and athletic trainers a firmer footing on which to decide when a concussed athlete has regained his or her pre-injury cognitive function and can safely return to play.

While many new tests are available to guide a coach’s or trainer’s decision to pull a player off the field, the neurologists made it clear that they are far from perfect. Even the best tests for mild traumatic brain injury may detect as few as 4 out of 5 concussions. And most of the tests currently available will unnecessarily remove an athlete from the field in 1 out of 10 cases.

Post-traumatic headache, fatigue and fogginess in the wake of injury, early amnesia, alteration in mental status or disorientation all are signs that may predict a longer course of recovery, the academy’s guideline indicate.

At the same time, neurologists and licensed healthcare providers who diagnose and manage concussion should make it clear to their patients that some concussion symptoms, including headaches, fatigue and difficulty concentrating, are to be expected in the days and weeks after injury and should get better with time. When a healthcare provider explains that bothersome symptoms can be attributed to concussion and provides reassurance that they will resolve — a process called “cognitive restructuring” — the guidelines note that a patient is less likely to develop chronic post-concussive syndrome.

But the neurologists also warn that for some athletes, return to play can never be free of risk. Amateur athletes with a history of multiple concussions or with concussion symptoms that persist should be warned that continuing to play puts them at greater risk of developing “permanent or lasting neurobehavioral or cognitive impairments.”

When neuropsychological testing reveals persistent impairment on the part of professional athletes in contact sports, the healthcare provider should “recommend retirement from the contact sport to minimize the risk for and severity of chronic neurobehavioral impairments,” the AAN guidelines say.